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Thursday, March 13, 2008

Nine days after the Alberta Tories captured yet another majority in the provincial election, Premier Ed Stelmach yesterday announced his new cabinet appointments.

One of the biggest changes is a portfolio swap between Dave Hancock, who was Minister of Health, and Ron Liepert (right), who was Minister of Education.

As was the case after the province's most famous trade -- the $15 million the Edmonton Oilers received in exchange for Wayne Gretzky -- what everyone wants to know is, who won? Will Mr Liepert be a better health minister than Mr Hancock was, or is healthcare getting short shrift?

DAVE HANCOCKMr Hancock wasn't wildly popular as health minister -- but, then again, he wasn't hated, either. There was some talk of Mr Hancock potentially losing his seat in Edmonton-Whitemud this year, but the results ended up going strongly in his favour.

Two major infection-control scandals in Vegreville and Lloydminster may have hurt his cause as health minister. As well, the Alberta Medical Association (AMA) had butted heads with Mr Hancock over Bill 41, a piece of legislation passed in December that gave the government the authority to take control of professional regulatory bodies, including the College of Physicians and Surgeons of Alberta, in emergencies like those in Vegreville and Lloydminster. Nevertheless, the AMA said both before and after the election that it would be happy to continue working with Mr Hancock.

RON LIEPERTJudging from Mr Liepert's Obama-like first pronouncement as health minister -- "Change has to take place" -- he's got big ideas. According to the Canadian Press, Mr Liepert will deliver an "action plan" for the province's healthcare system within the next month.

But really, it sounds like more of the same: "The current system is not working and it's not sustainable. It's obvious that more money hasn't produced a better product."

Based on the little that's been said so far, Mr Liepert is suggesting that the government control spending by implementing aspects of the 2002 Mazankowski report, which include increased competition in the healthcare sector and alternative revenue models -- code words in most circles for increased privatization. The Canadian Press reported that "he read the Mazankowski report this week and finds its recommendations are still as relevant today as they were when the report on reforming Alberta's health care system was released eight years ago." He also mentioned the 2002 Graydon report (PDF), which suggested charging Albertans a health insurance deductible of up to 1.5% of their annual income.

Now, the Alberta Medical Association is pushing for a renewed focus from the government on improving access to physicians, by providing more resources for training and recruiting doctors, nurses and healthcare workers. AMA president Dr Darryl LaBuick told me earlier this week about his priorities for the next session of parliament. "Some of the big areas are, of course, first of all, improving our primary care networks, access to primary care, and recruiting an adequate amount of physicians to our province, in general practice and specialties, surgery, psychiatry, pediatrics. And a more stable electronic medical record environment in the province."

"Part of what we're looking for in the health-care system is a need for predictability and the need for steady management and we've got a NASCAR driver, so hold on," said Laurie Blakeman, Liberal health critic.

"He's a NASCAR kind of guy, likes it fast and loud, fast and loose and puts his boots up on the desk and shoots from the lip."

Blakeman is skeptical about Liepert's knowledge in the health field, she said, since he doesn't answer questions or give meaningful input in the legislature.

Only time will tell whether healthcare will emerge the winner of this cabinet swap. But if Mr Liepert sticks to his word and moves forward and announces his plans as quickly as he has promised to, then we may know very soon whether this swap will benefit Albertans.

OTHER HEALTH NEWSAlso included in Mr Stelmach's announcement yesterday was the appointment of first-time MLA and former emergency physician Dr Raj Sherman as Mr Liepert's parliamentary assistant.

Dr David Swann, a Calgary Liberal MLA, was reelected with solid support. He's a fairly safe bet to continue on as the Liberal environment critic.

The 2008 Wellcome Image Awards highlight the best scientific imaging from research around the world. Peer into the internal structure of an HIV particle, see how sperm develop in the testes or the life and death of prostate cancer cells (right).

Genome Alberta and Genome Canada launched a similar project earlier this month: a digital art contest with a prize of $1,000 for first place. Its bent is decidedly more aesthetic than scientific though, since organizers ask that submissions depict the "intersection of science and society."

Of the three entries so far, which you can vote for here, one features a giant angel and another a giant turkey super imposed on a field of DNA entitled 'Getting Ready for Christmas.' Maybe each should come with an artist's statement to clarify these visions of science intersecting with society.

The field looks wide open and the deadline for submission is April 13. The winner will be announced at the 2008 International GE(3)LS Symposium in Calgary this April and may be featured here.

Why do doctors write?Anton Chekhov, Arthur Conan Doyle, W Someset Maugham (right), William Carlos Williams were all medical men who sought and found fame and glory through their writing.

Today, Michael Crichton, Robin Cook, Vincent Lam (left) and Kevin Patterson carry on the tradition. Increasingly, medical men (doctor-writers are still primarily male) are turning to journalism, with writers like Jerome Groopman and Oliver Sacks dominating the pages of the New York Times and the New Yorker, feeding a new insatiable public interest in all things medical. And even more recently, doctors have taken to blogging - that most democratic of forums - as an outlet for their writerly urges.

Here's a sampling of some of what we here at Canadian Medicine are talking about lately.

Some clinical trial participants in Prince Edward Island have been left out in the cold -- literally. Halifax dermatologist Barrie Ross tested a rheumatoid arthritis drug called anakinra to treat the rare disease familial cold autoinflammatory syndrome, a genetic disorder that causes patients to "feel like they're freezing from the inside out," reports the CBC. But now that the trial is over -- a big success, by the way -- the afflicted patients can't afford the $15,000-per-year medication. The government is "looking into the issue."

A recreational drug that had previously been mostly unknown is now becoming more popular in Canada, alluringly named "foxy methoxy." The appropriately named drug, a hallucinogen in the same family as magic mushrooms, is said to make one feel foxy -- or, as Canwest News describes it, it "can draw its users into sexual temptation." Want to learn more? I've found two very different explanations of the drug for your perusal: one, a good site on foxy from the University of Maryland's Center for Substance Abuse Research (some more slang terms for the drug: "Trash, Dip foxy, Roxy, Yum Yum, Muffy, Excite-bike, Five9"); the other, several definitions of foxy methoxy provided by Urban Dictionary (including a sample usage of the term that I defy anyone to explain to me: "Three schwags of fox to my nug grill! I blaze three foxes to my grill and nugged a dome past the schwag face!" Huh?)

Nine days of recruiting by Saskatchewan officials have netted the province 297 Filipino nurses. One concern for the recruiters was how to assuage the nurses' fears about the weather in Saskatchewan. "They shuddered at the temperatures but were excited," one official told the StarPhoenix. "They thought the images of frost on the trees and the frozen river were beautiful." At a time when the brain drain and health human resources poaching are major concerns, the province wanted to ensure it was recruiting ethically, so a policy was developed to recruit no more than 10 nurses from any one hospital in the Philippines. ("When you're going into another country, it is imperative to act ethically and ensure you don't leave their system in chaos.") So spreading the brain drain more thinly is somehow more ethical than decimating just one or two hospitals? According to the Saskatchewan officials, their "consideration" was "much appreciated."

Do doctors prefer men to women? It seems so, at least when it comes to recommending knee replacement surgery, according to a new study in the Canadian Medical Association Journal. "Physicians are prone to the same automatic, unconscious and ubiquitous social stereotyping that affect all of our behaviour," write the team of Toronto researchers. How far we've come... Particularly notable about this study, besides its dispiriting results, is its unprecedented methodology. For the first time ever, researchers sent real osteoarthritis patients as part of "Operation Knee" to visit unsuspecting physicians to measure gender bias, instead of using actors, according to Canwest News.

A woman whose 18kg tumour wasn't being treated quickly in Ontario decided to get treatment in Michigan, but the provincial government has refused to refund her $60,000 bill. "It's ludicrous," the woman told the Globe and Mail. "Where's the judgment and the integrity in all of this?... I'm disappointed with the bureaucracy of it all."

Dr Sanjay Gupta, CNN's resident doctor, graces the cover of our March issue, which is now online. Dr Gupta, who's a brain surgeon in his spare time, talked to us about his thoughts on the US presidential candidates' health platforms, his near-death experience in Iraq, his opinion of Canadian medicare and the burning question: who's sexier, him or fellow CNN-er Anderson Cooper.

PHYSICIAN WELLNESSFamily Day? Whose family? February is finally over. Did you get a day off?PLUSNRM Quiz: How family-friendly are you, doctor? Take the quiz online or click here for a printer-friendly PDF version

Tuesday, March 11, 2008

Welcome to Grand Rounds, the weekly anthology of the best writing from the medical blogs.

THIS WEEK'S TOP THREE

1 From Nurse Ratched's Place comes this week's most salacious post: "Sultry nurses seduce patients." Apparently a new survey conducted by Britain's Nursing Times found that one in 10 nurses think having sex with a patient is just fine, and one in six say they know a colleague who's done it. The controversy has been exacerbated by comments from Lord Mancroft, who called British nurses "grubby, drunken and promiscuous." But Nurse Ratched's Place author Mother Jones, RN isn't convinced: "... nurses are not sex crazed kittens looking for a hot date. We’re too old and tired to go to wild orgies after work. Sorry perverts. Start fantasizing about something else."

2 Training to become a doctor is akin to learning to sing opera, writes a Canadian med student in the Caribbean who knows of what he speaks, at Anatomy on the Beach.

3 We're willing to bet that husband and wife MD bloggers Dr J and Dr H, at Adventures in Medicine, are the northernmost physician bloggers in the world (check out the map to see where they are). They've made the bold claim that their hospital, in Iqaluit, Nunavut, has the best cafeteria in Canada. The menu features such delicacies as arctic char fillets and caribou stew. But locals prefer the recently re-opened burger joint called The Snack: "LDL is up, HDL is down, but people are happy."

The UK's four-hour goal for emergency room admissions is a nice idea, writes Mousethinks, but it's resulted in some very creative institutionalized truth-stretching. ER Nursey says American physicians may soon be faced with the same kinds of time limits, unfortunately.

MormonMDwonders if med students are all addled on Adderall and then muses for 11 paragraphs about why he never has time to go see a doctor. "Getting the smallest of chores done can become a mammoth task in the face of an 80 hour work week," he writes. "However, the fact remains, the things I really want done, get done, seeing a doctor does not."

Dr Kishore Visvanathan, a urologist from Saskatoon, Saskatchewan, has resolved to stop whining to med students who do rotations with him.

Rita Schwab discusses patient safety recommendations from Johns Hopkins researcher and physician Peter Pronovost, the man who's been pioneering the use of checklists in hospitals. (We wrote about his checklist project last month.)

A new study on sleep deprivation in MDs gave Dr Toni Brayer at EverythingHealth a bad case of the yawns. "I sleep less than anyone in my family or my friends. Is this a good thing? I don't know but it does allow me to indulge in blogging and reading and writing and yawn!!!! I'm tired."

Barbara Kivowitz at In sickness and in healthmeets a doc who seems to have skipped her patient-centred care seminar.

Patient-centred care? Poppycock, say the folks at Insure Blog who write: "Patients (and their care) ARE at the center of the health care system but at the same time we must recognize that patients are not paying the bills.... When patients pay the lions share of the bill they can and do have more say in their level of care."

MEDICAL SLANG

Before reading Dr ClaireBear's post, all the term "Toxic" evoked for Canadian Medicine was our fave pre-meltdown Britney Spears hit. Now we know that, at least among Filipino doctors and nurses, it's a catch-all adjective that roughly translates to any hellish healthcare-related person or situation. Hmm, maybe the folks at LA's Cedars-Sinai Medical Center could relate.

We were pleased by But You Don't Look Sick's review of the Jane Austen biopic Becoming Jane which compared it unfavourably to the BBC's Pride and Prejudice. We agree (although we confess we do like James McAvoy as a stand-in for Colin Firth).

This medical mystery from Healthline Connects is more PD James than Jane Austen, but we liked it: "A disabled man entered a hospital for care. He died. A multidisciplinary health care team may have hastened his death...that's sick. That's predatory. That's appalling. It's against the law. And it's wrong." Nuff said.

SEXING UP THE fMRI DOSSIER

Enough contributors wrote about fMRI that we had to give it its own section. We know, fMRI is very sexy. We don't think Canada can afford fMRI machines. Does this mean Canada's not sexy? Don't answer that.

The Samurai Radiologist's science side was turned on by new fMRI research that mapped brain differences in jazzers playing straight or improvised music. But the musician in him vows to "routinely deactivate major portions of my prefrontal cortex when I'm away from work, and let my instruments and my body move through the music on cerebellar cruise control alone."

Our psychiatrist friend at How to Cope with Pain is also hearing sweet music from an fMRI, in her case a study in which chronic pain patients "watch their fMRI readout, then use coping techniques to modify the fMRI readout," she writes.

ScienceBasegeeks out on why guys are bigger video game dorks than girls. Another fMRI study looked at male and female subjects while they played video games. Geek receptors in the guys' brains went totally nuts, apparently. (Canadians collectively ask: pretty please America, can we borrow your fMRI machines when you're done playing World of Warcraft?)

And speaking of video games, Dr Shockhips us to an electric shock add-on for Xbox and other video games called Mindwire V5, which allows you to "feel the game" while you play. Subjects from V1-4 trials could not be reached for comment. If Mindwire needs testers, Canadian Medicine hereby volunteers its services.

OTHER POSTS WE LIKED

Canadian physician Dr R at My Med Jokesremembers his 7th-grade sex ed course. "She said; 'Down below, the man has two holes and the woman has three holes. The baby comes out of that third hole. Any questions?' We looked at each other, feeling perplexed."

While we're on the subject, check out Hugh Laurie (in his pre-House days) and Stephen Fry's absurdist take on sex ed:

Vancouver's Dr Martina Scholtens, of FreshMD, recently recounted some unusual conversations: "Me, to a patient who has just detailed his heroin addiction: 'How many alcoholic drinks do you have each day?' Patient, with disgust: 'I'm no boozer! I don't touch the stuff.'" In her free time, Dr Scholtens is an avid knitter; here's the list of her knitting-related posts, including knitted brains (this one is by American physician Karen Norberg), a uterus and a digestive tract.

Removing a pyogenic granuloma from a patient's lip at an underequipped Guatemalan hospital is no big deal for Dr Paul Auerbach, a Stanford professor and wilderness medicine expert who blogs at Healthline's Medicine for the Outdoors. Be warned: gruesome photos ahead.

A heartbreaking story about treating Mr Schwartz, a former accountant who became homeless as a result of the medical costs associated with his late wife's breast cancer treatment, from NY Emergency Medicine.

Nova Scotia-born Dr Val Jones interviewed retired Canadian Senator Michael Kirby (pictured left), one of the country's leading health policy experts, on her blog Dr Val and the Voice of Reason. This audio Q&A is a great introduction to how the Canadian healthcare system works, among other things. I interviewed Sen Kirby last year about his new role as head of the Canadian Mental Health Commission, his proposed booze tax and being an irresponsible grandfather.

Fever-autism connection? David Williams at Health Business Blogasked pediatric neurologist Michael Segal for his take on the recent autism-vaccine decision in the US: "Vaccines often trigger some fever, and fever can trigger episodes of many inherited metabolic diseases, so the link between vaccines and autism may be more than just coincidence."

THE NEXT GRAND ROUNDS

Thanks to everyone who submitted, either on one of our disparate themes or on any healthcare-related topic.

If you like what you see here at Canadian Medicine, please feel free to stick around and check out some of our other posts. You can subscribe to receive Canadian Medicine by email by entering your address here:

Monday, March 10, 2008

When I was researching my new article on high-intensity focused ultrasound, or HIFU, one patient complaint kept propping up: there’s not enough information out there on this prostate cancer treatment or its side effects. A couple of patients I spoke to from the United States -- where the treatment is still unavailable (it's approved in Canada and Europe) -- struck out on their own in search of info and decided to go for the treatment, with mixed results. Here are their stories:

A prostatectomy? That's barbaric!Chicago businessman Peter Wenz got diagnosed with prostate cancer a year ago. “Someone from an online support group suggested I get a colour flow Doppler test done and in the process, the urologist found a second tumour at the apex of my prostate,” he says.The tricky location of the second tumour limited Mr Wenz’s treatment options to radiation and androgen deprivation -- which, according to new research, actually makes the cancer spread -- until he brought up HIFU. His urologist encouraged him to pursue the option, and shortly afterwards Mr Wenz jetted to Germany for the treatment.

The procedure was a success and a test showed that his PSA levels were undetectable -- the cancer was zapped. Although he did develop urethral strictures, he chalks those up to the transurethral resection of the prostate (a procedure that was done along with the HIFU in order to speed up the recovery). Three months and a few dilation treatments later, Mr Wenz is doing well -- erectile function is normal and urinary function is getting there. He is on his way to a complete recovery and has become a big HIFU advocate.

“Compared to all other modalities, only HIFU and cryotherapy specifically target the cancer cells, you just go in and only destroy that area,” he says. In fact, he believes those minimally invasive procedures will change the way prostate cancer is treated in the future. “The day will come when radical prostatectomies will be looked at the way we look at lobotomies. It’s barbaric -- it completely destroys the quality of life!”

Not sold on itSixty-nine-year-old Fred Gillick was diagnosed with prostate cancer nearly 12 years ago. He was initially treated with external beam radiation and seed implants, but four years later, cancer reared its ugly head again. His doctor told him there was nothing more to be done, but Mr Gillick had heard about HIFU through a cancer support site. So he went for it. Unfortunately, the previous radiation treatment had left its mark on him and the salvage procedure just made matters worse. He is now impotent, in constant pain and wearing a permanent catheter. And his cancer is still there. “There’s very little hope,” Mr Gillick told me in a phone interview.

Strictures of hopeFirefighter and paramedic Eric Sondeen is one of those patients who chose HIFU. The Boulder, Colorado resident got the call a year ago, on Christmas Eve. His PSA levels were through the roof — he had prostate cancer. His urologist suggested HIFU, so Mr Sondeen did what most patients do these days: he went online.

"I did a lot of research and it looked like the best option," he recalls.

Since the treatment is not yet approved in the US, though clinical trials are underway, Mr Sondeen joined the ranks of medical tourists and headed to the Dominican Republic — with his urologist. All was well in the beginning, the cancer was flushed out and everything was in working order.

But at month four, trouble struck. Mr Sondeen developed urethral strictures — scar tissue was clogging up his urethra, making urinating difficult and downright painful. It's got to the point that he now has to self-catheterize on a regular basis to empty his bladder.

He now says he wishes he'd weighed his options a little more carefully — and not believed the hype. "The incidence of urethral strictures is actually closer to 20% according to one study," he says, "rather than the 2% presented to me and my doctor."

Mr Sondeen is now looking into repair treatments. But, despite his difficulties, he remains optimistic about the future of HIFU. "I think I was among the percentage of people to take a bullet for this so we could all learn about it," he says. "I wouldn't want to throw the technology out with the bathwater."

JUST THE FACTSFor more information on HIFU, visit Dr Ian Brown’s Niagara HIFU clinic website and Dr William Oravan’s Maple Leaf HIFU clinic. Both offer detailed information on the procedure and who is most likely to benefit from it.

Another great site is Australian Terry Herbert’s prostate cancer support site. It offers sufferers a forum to discuss their experiences with various treatments on an ongoing basis. Patients exploring their options can look up the treatments and see the longterm prospects of each. It’s all there: the good, the bad and the ugly.